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One in six patients with heart failure with reduced ejection fraction (HFrEF) develops worsening HF within 18 months of an initial diagnosis, according to research published in the Journal of the American College of Cardiology, and these declining patients aren’t receiving the right standard of care.

“Heart failure is a progressive condition,” study author Javed Butler, MD, MPH, MBA, of the University of Mississippi, and colleagues wrote in JACC. “Considering the high risk of adverse outcomes, there is growing interest in conducting clinical trials with novel interventions in both acute and chronic settings in patients with worsening HF.”

The understanding of worsening HFrEF, on the other hand, is less comprehensive, Butler et al. said, and existing data provide “a limited understanding of this clinically important, growing and costly problem.” To add to current knowledge, the team conducted an analysis of more than 11,000 HFrEF patients enrolled in the PINNACLE registry.

Patient data were linked to pharmacy, private practitioner and hospital claims databases, according to the study. The authors assessed the incidence, clinical characteristics, treatment and outcomes of subjects with worsening HF, which was defined as more than 90 days of stable HF with complications that required intravenous diuretics.

Of 11,064 HFrEF patients, 17 percent developed worsening HF an average of a year and a half after their initial HF diagnosis. Those who had worsening heart failure were more likely to be black, octogenarians and have a higher comorbidity burden.

At the onset of worsening HF, Butler and co-authors reported 42.4 percent of patients were on monotherapy, 43.4 percent were on dual therapy and 14.1 percent were on triple therapy. In addition, 48 percent, 61 percent and 98 percent of patients were taking more than 50 percent of the target dose for angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists, respectively.

The mortality rate after two years was 22.5 percent, and 56 percent of patients were rehospitalized within a month of their worsening HF diagnosis.

The authors said further prospective studies will be needed to develop more effective management strategies for these patients that will, hopefully, improve their outcomes.

“Patients who develop worsening HF have a significantly greater comorbidity burden, and their outcomes are poor,” Butler et al. wrote. “The treatment regimens of patients with HFrEF who develop worsening HF may not be optimized before or after the development of worsening events, as well. In addition to significant opportunities to improve pharmacotherapy to prevent or delay the development of worsening HF or its complications, there is also a need for novel therapies for patients with worsening HF, especially those who do not tolerate available therapies.”